1. CAS –Strategy, Pitfalls, and Safety Issues
Ralf Langhoff

2. Ten Steps of Carotid Stenting
1. Vascular Access (femoral - brachial)
2. Angiographic evaluation
3. Guiding Sheath Placement
4. Crossing the Stenosis
- without protection
- with distal protection
- with proximal protection
5. Lesion predilatation
6. Stent Deployment
7. Postdilatation
8. Removal of Protection Device
9. Final Angiographic Control
10. Sheath removal/ Access Care

3. Carotid Access Can I safely Get There? CCA Access
Distal Protection Device into ICA

4. Carotid Access Determinants
Aortic Arch Type
CCA/ECA Disease
Carotid Tortuosity

5. Different Types of the Aortic
Arch

6. Truncus bicaroticus

7. Prefered Catheters Aortic Arch Type I Vertebral tip Judkins right
Head Hunter
JB 1
Berenstein
Weinberg

8. Prefered Catheters Aortic Arch Type III JB 2 Newton Sidewinder Vitek
Catheter tip should be
formed in abdominal aorta
or subclavian artery

9. Accessing the CCA Tips Beware of adverse anatomy, ie.
Type II and III aortic arch
Irregular contour of proximal CCA on angiography
Kinking / coiling of CCA
To avoid vessel wall trauma, use of soft and flexible
catheters that do not scrape the aorta (prograde cath.)
Go from the easiest to the more complex approach
Don't try to hard for too long !
It is better to refer the patient to CEA than to inflict
permanent damage!

10. Critical Issues Should I choose Guide Catheter or Guide Sheath?
Should I Keep Guide C/S In distal CCA
or proximal CCA ?
When do I Choose Large Size Guide C/S?

11. Critical Issues Should I choose Guide Catheter or Guide Sheath?
Individual Preference
GC more stable, allows torque
GS smaller size, smoother transition (No ledge
effect)
Carotid Tortuosity
GC allows torque
Remote Carotid access
GC more stable

12. Situations where guiding catheter is preferred
Accessing the CCA
Situations where guiding catheter is preferred
Calcified aortic arch
Elongated aortic root
Ostial lesions of CCA
Tandem lesions
Bovine arch (left carotid)
Tortuous common carotid
Tortuous iliacs
8 Fr Guide in Aorta maybe of advantage

13. RCC
5 F Diagnostic
6 F Sheath

14. Accessing the CCA Conclusions
It is important to realize that embolic events
may be elicited " on the way" to the target lesion,
that is before the lesion has even been touched
A skillful and cautious approach using
appropriate endoluminal equipment may help
to avoid emboli-related complications
Access is the major issue
The "easy parts" are
EPD and Stentplacement

15. Carotid Filter Issues Should I Pre-dilate Before Filter Placement?
What to do with slow Flow/ Occlusion in a filter?
Filter filled?
Carotid Spasm?
What to do when the retrieval sheath
fails to advance?
How to handle a detached filter?

16. Carotid Filter Issues Carotid Tortuosity Should I Pre-dilate Before
Filter Placement?
Carotid Tortuosity
Fixed Wire Filters
Pre-dilate severe stenosis
Reduces friction during filter travel
Bare Wire Filters
No need to pre-dilate
In-situ Wire Filters (Spyder)
No need to pre-dilate

17. Carotid Filter Issues Should I Pre-dilate Before Filter Placement?
Carotid Complex
Lesion Morphology
Sharp Entry Angle
Sharp Exit Angle
Absent clear path
through Lesion
Subtotal

18. Carotid Filter Issues What to do when filter doesn't advanve?
Power Guide support
Pre-dilatation
Buddy-wire
Buddy-Catheter
Bare wire/Spyder
proximal Protection
Percusurge

19. Carotid Filter Issues What to do with slow flow / occluded Filter ?
Filling defect below filter dots
Aspirate with, e.g.Diver®
Close Filter
Filling defect above filter dots
Close filter and remove
Incidence
slow flow %
Aspiration 2-5%

20. Carotid Filter Issues What to do with slow Flow/ Occluded filter?
Are filter Dots Closed?
Yes
Carotid spasm
Give Nitro No
Filter slow flow due to emboli
Retrieve Filter

21. Asymptomatic Flow Obstruction
Spasm

22. Asymptomatic Flow Obstruction
Filled Filter

23. Filter Detachment RC Catheter advancement problem
Filter Slides down and
impinges on stent
Guide catheter prolapse
into Aorta pulls Filter down

24. Filter Detachment Preventive Strategies Avoid cases with poor landing
zone
Always keep guide tip in view
Never force to pull the Filter into RC
Change RC Type (Accunet?)

25. Carotid Filter Issues What to do when Retrieval
Catheter doesn't advance?
Anatomical Adversity Issues
Carotid Tortuosity
Sharp Lesion Angles
Guide Wire bias
Inadequate post dilatation
Open cell stent design with
"gater backing"
Calcified lesion

26. Carotid Filter Issues What to do when Retrieval
Catheter does not advance?
Don't panic and pull on filter!
Neck rotation
Advance sheath distally
Bent tip retrieval sheath
Buddy-wire
Additional balloon dilatations
Neck Compression

27. Carotid Stent Issues Should I Pre-dilate Before Stent-Placement?
Carotid Stent Profile
Tip of Stent Delivery System
Carotid Lesion Severity
Carotid Tortuosity
Operator Experience
Carotid Lesion Complex
Morphology
Sharp Entry Angle
Sharp Exit Angle
Heavy Calcification

28. Should I Post Dilate After Stent Placement? Objectives
Minimal final lumen
diameter
Safe retrieval of DPD
Open cell design stent
Avoid stent migration

29. Hands off!

31. Take Home Message Avoid These S STEEP Arch (Type III)
SEVERE Tortuosity
SHARP Entry Angle
SHARP Exit Angle
INSUFFICIENT Landing Zone
UNSATISFACTORY Collaterals

32. Thank You for Your Attention!
Ralf Langhoff